Fishing and Camping ClubAll Grade Levels/One on One Adult Supervision RequiredDates: 10/7, 11/4, 12/2, 01/13 Location: Clermont Cost: $100 per person Fishing and Camping ClubComplete this form and submit payment for your child to participate in Fishing and Camping Club. If you are paying for more than one child, an individual permission and payment form must be completed for EACH child. Student Name(Required) First Last The undersigned, who is the parent/guardian of named above, a minor (hereinafter referred to as “Student”), on behalf of himself and student, their personal representative, assigns, heirs and next of kin, request Student is permitted to participate in the aforementioned event:Acknowledgements(Required) Hereby releases, waives, discharges and covenants not to sue, Pace Brantley Preparatory School, their officers, employees and agents, all for purposes herein referred to as Releases, from all liability to the undersigned and Student, their personal representatives, assigns heirs and next of kin, for all loss or damage, and/or claims, demands, causes of actions or suit of any kind therefore, particularly on account of injury to the person or property or resulting in the death of Student, whether caused by the negligence of Releases or otherwise, while Student is a participant in the aforementioned event; Hereby agrees to indemnify and save and hold harmless the Releases and each of them from any loss, liability, damage, or cost they may incur while Student is a participant in the aforementioned event, whether caused by the negligence of the Releases or otherwise; Hereby assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releases or otherwise while Student is a participant in the aforementioned event; Hereby agrees that if any portion of the Agreement is held invalid, that the balance shall, notwithstanding, continue in full legal force and effect. Typing your name in this box serves as your official signature on the Fishing and Camping Club Permission Form(Required) First and Last NameMedical Information: In the event Student becomes ill, I authorize the faculty or chaperones to obtain medical attention at a physician’s office or hospital. Student is covered by the following medical insurance:Insurance Company Name(Required) Group Number(Required) Allergies(Required) If none, type noneChronic/Acute Illnesses(Required) If none, type noneI UNDERSTAND THAT EVERY EFFORT WILL BE MADE TO REACH ME BEFORE MEDICAL PERMISSION IS GIVEN TO TREAT MY CHILD.Home PhoneParent/Guardian Work Number(Required)Parent/Guardian Work NumberParent/Guardian Cellphone Number(Required)Parent/Guardian Cellphone NumberTyping your name in this box serves as your official signature confirming medical information.(Required) First and Last Name Email(Required) Names of Additional People Attending Non StudentsProduct Name Quantity(Required) Price: $100.00 Quantity Total Credit CardCard Details Cardholder Name
